We report a fatal case of post-partum streptococcal toxic shock syndrome in a patient who was previously healthy and had presented to the emergency department with an extensive blistering ecchymotic lesions over her right buttock and thigh associated with severe pain. The pregnancy had been uncomplicated, and the mode of delivery had been spontaneous vaginal delivery with an episiotomy. She was found to have septicemic shock requiring high inotropic support. Subsequently, she was treated for necrotizing fasciitis, complicated by septicemic shock and multiple organ failures. A consensus was reached for extensive wound debridement to remove the source of infection; however, this approach was abandoned due to the patient's hemodynamic instability and the extremely high risks of surgery. Both the high vaginal swab and blister fluid culture revealed Group A beta hemolytic streptococcus infection. Intravenous carbapenem in combination with clindamycin was given. Other strategies attempted for streptococcal toxic removal included continuous veno-venous hemofiltration and administration of intravenous immunoglobulin. Unfortunately, the patient's condition worsened, and she succumbed to death on day 7 of hospitalization.
A young man presented to our centre needing an urgent debridement of his postcraniotomy wound due to massive myiasis during the COVID-19 pandemic in October 2020. Prior to the surgery, his nasopharyngeal swab real-time PCR test result was unknown. One day later, it returned as SARS-CoV-2 positive. All healthcare workers who were involved in the patient management avoided cross infection as they wore appropriate personal protective equipment. This article depicts the importance of adequate preparations when handling potentially infectious patients and the perioperative issues associated with it.
Necrotizing fasciitis (NF) is a deadly soft tissue infection causing a significant morbidity and mortality. Abdominal and chest wall NF are unusual. We describe a 49-year-old male with anterior abdominal wall NF secondary to per- forated gastric ulcer (PGU). He was admitted in septic shock presenting an abdominal wall NF with severe metabolic acidosis requiring dialysis and admission to the intensive care unit. There was a patch of gangrene with surrounding skin discoloration at lower quadrant of the abdominal wall. Local debridement was done without a preoperative computed tomography that was performed after surgery. Adequate source control was not achieved after the second surgery and the patient had worsened resulting to death. We describe this rare presentation of NF and discuss the issues learnt from this unfortunate event.
Osteomyelits due to concurrent multi-drug resistance organisms is difficult to treat for any surgeon and infectious disease physician. An eleven-year-old boy presenting with an open fracture of the left radius and ulna after a fall in a stagnant wet field. Despite prophylactic antibiotics and surgical intervention, the open wound was infected, and Chromobacterium violaceum as well as Klebsiella pneumoniae were isolated. He was treated with six weeks of parenteral cefepime and amikacin and was discharged upon clinical improvement. Unfortunately, chronic osteomyelitis set in with persistent sinus drainage. He then underwent a second procedure for debridement of the wound and Burkholderia pseudomallei was isolated. Parenteral antibiotic therapy was initiated progressing with a marked improvement. However, the long course of antibiotics had exhausted the patient and his family, leading to a premature interruption of the parenteral antibiotic. Despite the suboptimal antibiotic course, there were no signs of relapsed osteomyelitis during subsequent review. The timely surgical intervention with appropriate sampling for subsequent microorganism isolation guided the suitability of the treatment line.
The presence of lytic lesions in the bones of foot raises a number of diagnostic possibilities ranging from infection, inflammatory pathology to neoplastic conditions. Although the radiological picture is not pathognomonic of any pathology, clinical history and histopathological examination can help to clinch the diagnosis. We present a case of multiple lytic lesions of the foot and discuss possible differential diagnoses. The patient was diagnosed as a case of madura foot and the lesions responded to surgical debridement and anti-fungal treatment with a good functional outcome. Madura foot is an uncommon, chronic granulomatous fungal or bacterial infection with a predilection in people who walk barefoot. Although known for a specific geographical distribution, madura foot should be kept as a possible diagnosis in patients presenting with lytic lesions of the foot due to population emigration across the world.
Infection following grade IIIB open tibial fracture is common. The primary aim of managing this condition is to achieve control of infection before the bone reconstruction procedure is performed. The outcomes for such patients have not been evaluated in the literature. This study was conducted to examine the outcome of a multi-stage procedure for the treatment of infected grade IIIB open tibial fractures.
Introduction: Large wounds in the leg require combination of local flaps or free flap for wound coverage. Gastrocnemius musculocutaneous flap (GMCF) allows a large wound to be covered by a single local flap. However, the conventional GMCF is often associated with donor site morbidity where the exposed soleus raphe causes poor uptake of the skin graft. Islanding the skin on the muscles allows the donor site to be closed primarily, thus avoiding the donor site morbidity. Materials and Methods: Medical records of twelve patients who underwent islanded GMCF surgery from 2004 till 2018 were reviewed retrospectively. Results: The mean age was 31 years old. Eight cases were with open fracture of the tibia, two degloving injury exposing the patella, one open fracture of patella and necrotising soft tissue infection. The wound size ranged from 12cm2 to 120cm2. All flaps survived. Three patients required skin grafting at the donor site while in the rest the donor sites were able to be closed primarily. Four patients developed deep infection, one healed after vacuum dressing, one after bone transport and one after split thickness skin graft. One patient ended up with below knee amputation after developing chronic osteomyelitis of the tibia. Conclusion: Islanded gastrocnemius musculocutaneous flap is an effective simple alternative for coverage of large soft tissue defects from the knee to half of the leg distally with minimal donor site morbidity. Aggressive debridement of unhealthy tissue is necessary to prevent infection following wound coverage with this flap.
It is very rare indeed in the practice of children's orthopaedics today in Malaysia that the natural history of long bone osteomyelitis is seen. A case is presented where a shoulder abscess in a 3-year-old child developed into septic arthritis of the shoulder and subsequently chronic osteomyelitis of the adjacent humerus. The parents refused active surgical debridement and sequestrectomies. Three years later the child had regenerated a new humerus over the sequestra. Radiographs are presented illustrating the entire natural history of osteomyelitis with the regeneration of a new humerus.
Total talus dislocation is a rare injury and is commonly accompanied by associated fractures. Common worrisome sequelae are infection, avascular necrosis and post-traumatic arthritis. We report here on a patient who sustained an open total talus dislocation with an ipsilateral medial malleolus fracture. Following early debridement, reduction and a combination of internal and external fixations, early recovery was good with no evidence of avascular necrosis.
This study aimed to detect the presence of enterococci in the root canals of untreated and treated teeth with periapical disease and to compare this to their presence in the saliva and in the immediate surgical environment during root canal treatment. Using an aseptic technique, 33 samples were obtained from 27 untreated and 6 previously treated teeth associated with apical periodontitis. Reduced Transport Fluid (RTF) was used as transport medium. Saliva samples and areas in the surgical environment were also sampled. These were performed prior to chemo-mechanical debrjdement and obturation for every case. The saliva was diluted to 10- J and was plated on Bile Aesculin Azide (BEA) agar whereas the rest of the samples were plated on Bile Aesculin (BE) agar. These plates were then incubated aerobically at 37°C for 48 hours. All the colony types that blackened the agar were sub-cultured to obtain pure isolates and tested on 6.5% sodium chloride (NaCI). Growth on this medium was Gram stained for further confirmation of cell morphology. Gram positive cocci isolated from previous positive test were identified as enterococci. Enterococci were recovered from untreated cases only; from 2 teeth (in 2 patients) prior to chemo-mechanical debridement, from 3 teeth (in 3 patients) prior to obturation and I from saliva sample. A 'total of 5 samples from 5 different patients were positive for enteroco•cci. Sampling in the immediate surgical environment revealed a low occurence in the range of3.0% (1/33) to 15_2% (5/33). In conclusion, the occurence of enterococci in patients and the immediate surgical environment was low number.
Chronic apical periodontitis associated with dental pulp necrosis is the main cause of odontogenic extraoral cutaneous sinus openings. These tracts are often initially misdiagnosed unless the treating clinician considers a dental aetiology. This case report of a 19-year-old woman describes the diagnosis and treatment of an extraoral cutaneous sinus tract of odontogenic origin. Non-surgical conservative endodontic therapy was opted as the involved teeth were restorable. One month after the completion of obturation, there was closure of the sinus tract. One year follow-up showed complete resolution of the sinus tract with minimal scar formation.
We report here a rare presentation of an extra-nodal non-Hodgkin's lymphoma. Both clinical presentation radiological findings were suggestive of psoas abscess. Surgical debridement was performed and histopathological examination of the tissue sample revealed the diagnosis of non-Hodgkin's lymphoma. It is therefore important to note that non-Hodgkin's lymphoma can mimic psoas abscess and that psoas lesion with vertebral involvement does not necessarily indicate infection. It is always advisable to obtain needle biopsy to establish diagnosis before embarking on surgical intervention. The practice to send any suspicious tissue obtained intra-operatively for histopathological examination is also warranted.
Postoperative wound infection in an instrumented spine patient is often disastrous. Management includes implant removal leading to spine instability. Negative pressure wound therapy (NPWT) applied to the spine surgical wound is one of the wound care technique with successful results. We report a case of a man who sustained Chance fracture of Lumbar 1 (L1) vertebra treated with long segment posterior instrumentation, who unfortunately developed Extended-spectrum beta-lactamase (ESBL) positive E. coli infection one month after the operation. After careful debridement of the wound, the implant became exposed. Three cycles of NPWT were applied and the wound healed with granulation tissue completely covering the implant, and thus negating the need to remove the implant. In conclusion, the NPWT is a good alternative in postoperative wound management especially in an instrumented spine patient.
Necrotizing fasciitis is a limb- and life-threatening rapidly spreading infection affecting the deep fascia with secondary necrosis of the subcutaneous tissue. It requires immediate medical attention and emergency surgery to prevent morbidity and death. This study was undertaken to determine its co-morbidity and risk factors affecting the outcome of its surgical treatment. This is a retrospective review of 36 cases of necrotizing fasciitis of the lower limb treated in our center between 1998 and 2002. Only 19% of the cases were correctly diagnosed upon admission and 48.6% were initially diagnosed as 'cellulitis'. Diabetes mellitus was the most common co-morbid. Pseudomonas, Staphylococcus, Streptococcus and Enterobactericae were the common pathogens isolated. Ten patients (27.8%) had major amputation as part of radical debridement. The overall mortality rate was 36% with laboratory parameters: high serum urea and creatinine, and low haemoglobin levels were predictors for higher mortality. Poor white cell response which is common in diabetic patients and a delay in surgical debridement were. notable attributes to a higher mortality. Necrotizing fasciitis is a serious infection associated with significant morbidity and mortality. A poor white blood cell response, high serum urea and creatinine, and low haemoglobin level were the predictors for mortality. Early diagnosis and prompt treatment are of paramount importance in the treatment of this infection.
Necrotizing fasciitis of the head and neck is a rare, rapidly progressive infection involving the skin, subcutaneous tissue and fascia. We report three cases of necrotizing fasciitis that differ in their presentation and outcome. The first case involves a patient who presented with progressively enlarging anterior neck swelling that was later complicated by dehydration and reduced consciousness. The second case is a patient with neck swelling and ipsilateral otorrhea. The third case concerns a patient with a buccal ulcer complicated by ipsilateral facial swelling. All of them underwent a fasciotomy with wound debridement with the addition of a cortical mastoidectomy in the second case. Two of these patients recovered well. Unfortunately, the third case succumbed to death due to airway compromise and septicaemia. We advocate the importance of eradicating the source of infection followed by frequent, meticulous wound dressing and strict blood sugar control to obtain better outcomes in managing necrotizing fasciitis of the head and neck. However, involvement of the airway carries a grave prognosis despite aggressive treatment.
A 31-year-old Pakistani man was admitted to hospital after sustaining a Grade I compound fracture of the mid-shaft of the left tibia and fibula following a motor vehicle accident. He developed septicaemic shock, acute renal failure and Group A streptococcal necrotizing fasciitis of the left leg. The patient underwent an above knee amputation followed by disarticulation of the left hip with extensive debridement. He was treated with benzylpenicillin, vancomycin, inotropes and continuous haemodialysis and survived without further sequelae. Subsequently, skin grafting was done over the wound site. This case highlights the role of Group A streptococcus as a cause of this rare and life-threatening infection.
Nail bed injuries were commonly found concomitantly with fingertip injuries. Reconstruction of fingertip including the nail bed should be attempted at acute stage. Aim of the surgery was to restore as much finger length and achieve normal nail growth. In chemical burns, the initial presentation might not reflect the exact extent of injury. Appropriate acute management must be initiated while waiting for demarcation. We report a case of young stewardess who presented with fingertip chemical burn injury. Surgical debridement was done on third day post-injury. A cross-finger flap to cover skin defect and split-thickness nail bed grafting from the remnant of injured finger were done. Excellent functional and cosmetic outcome was achieved in 6 months. Surgical treatment in a chemical burn was similar to traumatic injury. Nail bed graft was the best option for nail bed reconstruction. In cases of soft tissue loss, advancement or pedicle flaps are beneficial.
A 47-year-old gentleman, with underlying seborrhoeic dermatitis that was treated with steroid therapy, and hepatitis B, presented with pain in his right hip. He was diagnosed with stage 2 osteonecrosis of the right hip (Ficat and Arlet classification). Core decompression and bone grafting was performed but recovery was complicated by a surgical site infection. Wound debridement, removal of bone graft and clearance of the bone tunnel were carried out. The patient was allowed to bear weight after surgery. Twelve days later, he developed right hip pain and radiographs showed fractured femur neck; the patient then underwent a two-stage total hip replacement (THR).
This is prospective case-control study of more than 18 months performed to assess the effectiveness of maggot debridement therapy (MDT) with the sterile larvae of Lucilia cuprina (a tropical blowfly maggot) for the treatment of diabetic foot ulcers. Literature thus far has only reported results with the temperate maggot, Lucilia sericata. This study documents outcome in diabetic foot wounds treated with maggot debridement versus those treated by conventional debridement alone. In this series of 29 patients treated with MDT, 14 wounds were healed, 11 were unhealed and 4 were classified under others. The control group treated by conventional debridement had 30 patients of which 18 wounds were healed, 11 unhealed and 1 classified under others. There was no significant difference in outcome between the two groups. The conclusion that can be made from this study is that MDT with L. cuprina is as effective as conventional debridement in the treatment of diabetic foot ulcers. It would be a feasible alternative to those at high risk for surgery or for those who refuse surgery.